estrogen

Congratulations! You passed your final exam in IVF 101 and now are ready to get into the details of the IVF process in IVF 102.

In IVF 101 we described all the players in the IVF game. The first and one of the most important members of your baby dream team is your Reproductive Endocrinologist (RE). His title alone should give you a bit of insight into what all this In Vitro business is all about. Note that your RE is not called “Chief Baby Maker In Charge.” He does not hold a specialized degree in “Getting People Knocked Up”.

Sure, the emphasis of his training is to figure out how to get you pregnant, but the job title alone is an indication that what he really does is try to get your endocrine system and all its hormones working together to set the stage for pregnancy. Your RE is essentially an endocrine system manipulator and he has a variety of ways to adjust your hormones and help you make a baby.

It is impossible to describe all the different ways he can do this in one simple post. Because each of us is unique, the plan your doctor will give you is tailored to your needs. I can’t possibly speak to your individual situation. However I can give you an overview of the basics of the stages involved in IVF.

Step One- The Human Pin Cushion

Think all your needle woes begin when you start taking your IVF medication? Think again. When you sign up for IVF you and your partner will go through a ridiculous amount of diagnostic testing. Even if you completed many tests with your OB/GYN before moving on up to the big time, you will likely do it again. For the mommy wannabe, the clinic will test various hormone levels to make sure they are in the proper range. Tests will also be done on the thyroid to ensure its functioning properly. The RE could decide to run a number of other labs to rule out the possibility of autoimmune issues, although this was not done for me until we had a couple of failed cycles on the books.

Image by Phillipa Willitts via Flickr

Some tests like the sonohysterogram or hysteroscopy don’t involve needles but still totally violate you and remove any remaining modesty you had prior to turning to IVF. These tests involve checking your uterine cavity and fallopian tubes to look for potential clues as to why embryos aren’t implanting for you.

Your spouse, partner or sperm donor will also provide a sperm sample to inspect that his part of the equation is doing its part.

Image by Gerda via Flickr

All involved parties will be tested for communicable diseases prior to beginning the first cycle. If you have experienced multiple IVF failures or miscarriages, or if one of you has a family history of genetic disorders, you may also receive karyotyping (genetic testing) to rule out problems based on how you and your partner’s genetic codes match up.

Finally, the RE will perform a mock embryo transfer in order to take note of the layout of the mama-to-be’s anatomy and measure exactly where an embryo should be placed at the actual transfer. A smooth transfer is a strong indicator of pregnancy and live birth rates. It’s better for the embryos and implantation if the RE has a road map with a path planned out before the embryos come back to you.

Step Two- Turn Out the Lights, The Party is About to Begin.

So you made it to step two? That’s something to celebrate because step one can throw some nasty curve balls capable of making Nolan Ryan’s jaw drop.

Once you are cleared for take-off the RE may find a way to shut down your natural hormones so he can take over and manipulate your cycle. That is if you are doing an agonist protocol.

Here is where things get hairy and the approach diverges based on the patient and clinic. There are two types of basic protocols. In an agonist protocol your doctor will shut down your pituitary gland or “down regulate” your hormones using a drug called lupron for 10 to 15 days prior to starting stimulation meds. For this reason, this protocol is often called a long lupron protocol. As the name suggests, this protocol takes a bit longer than the other protocols.

The other type of protocol is an antagonist protocol. It’s a much shorter process since there is no down regulation prior to starting stimulation medications. Instead, your doctor will protect against premature ovulation and control the speed of your response to stimulation meds using one of two antagonist medications on the market, Ganirelex or Cetrotide. They are the same thing produced under different brand names. These medications will be started on day four to day seven of stimulation.

In any protocol, the RE will often have some control over your cycle by placing you on birth control prior to the start of your cycle month. Not all clinics use birth control pills but most do these days to help bring a little bit of predictability to an otherwise unpredictable process.

Yes, it is ironic. If I had all the money I paid for birth control when I didn’t know I didn’t really need it I could almost pay for a full IVF cycle. Almost. But here we are taking birth control again in an attempt to get pregnant.

Go figure.

Lupron, Ganirelex, and Cetrotide are all subcutaneous injections (tiny thin needle injected into soft tissue). This means less pain at administration. Yay!

Step Three- Fueling the Baby Making Machine.

Sometime in the first few days of your menstrual cycle you will begin taking the most important and priciest of hormones in IVF, follicle stimulating hormone (FSH). The three main gonadotropin brands are Follistim, Gonal-F and Bravelle. Once again, they are essentially the same and marketed under different names.

Your treatment may include some form of Menotropin (hMG) instead of a gonadotropin or in combination with it. Menotropins contain both FSH and leutenizing hormone (LH) extracted from the urine of menopausal women. Not only is this gross, but it does make one wonder, “Who are these women and what do they get paid for this?”

Image by Angie via FlickeApparently their urine is also pretty creative

Menopausal women have a lot of FSH in their urine because the hormone is no longer being used by their follicles and therefore passes right through their system. The difference between gonadotropins and menotropins is that the latter also contain (LH) which is found in Lupron and used to either suppress or start ovulation depending on the amount and timing.

Menotropins were the earliest form of stimulation medications and existed before the FSH only drugs (also called recombinant FSH) were created. There are many brands of menotropins but the main ones are Menopur, Repronex, and Pergonal. The first IVF baby was created using Pergonal. Many studies have been done comparing pure gonadotropins to menotropins and live birth rates are the same. Your doctor may combine gonadotropins and menotropins for low responders, those of us that need a lot of FSH to scream at their ovaries.

In a natural cycle, the FSH hormones kick off the development of multiple follicles in the ovaries. Each follicle holds an egg and in the beginning of your menstrual cycle many follicles begin to expand and grow.

However once one follicle is large enough to begin producing an ample amount of estrogen (8 to 10 mm), the estrogen being produced by the follicles builds up and sends a signal that causes the body to decrease the FSH. The decrease in FSH has the effect of quieting the rest of the follicles and leaving only the one dominant follicle to continue to grow and mature. In the case of fraternal twins, two follicles continue to grow and release eggs.

Unlike a natural cycle, in an IVF cycle we add greater amounts of FSH and keep the level consistently high in order to “recruit” as many of these follicles as possible to grow and fully mature. This will give the infertile patient many eggs instead of the one that would typically be released naturally, allowing the couple many opportunities at a healthy baby from only one cycle month.

FSH essentially tells your ovaries “Hey, let’s grow some follicles!”. For some women, all they need is a whisper from FSH to get a response because receptors in their follicles are very reactive and “hear” the FSH well. Others need a lot of FSH to scream “HEY LET’S GROW SOME FLIPPIN’ FOLLICLES ALREADY!!!” at their ovaries in order to get things going.

Image by Danny via Flickr

This can cause the cost of drugs to vary a great deal and is also the reason you may find your RE will increase or decrease your meds after monitoring your blood work and ultrasounds. Making adjustments isn’t a good or bad thing, your doctor is conducting a symphony of hormones and feels like the sound needs to be adjusted to make the beautiful music of pregnancy.

Like the antagonists, all hormones used in this stage of the process are typically injected subcutaneously. Double yay!

The stimulation part of the process can take as few as six days to more than 20 in poor responders. However most women take stimulation medications for around 10 days. You will be monitored every two to three days to assess size of your ovaries, your follicles, estradiol levels, and also to guard against hyper stimulation which can be dangerous. Your RE will also be looking for a nice thick uterine lining with a clear triple layer pattern. Most clinics like to see the lining at at least 7mm prior to retrieval.

Once you have follicles measuring at least 18mm-20mm and your estrogen is in the right range, its time to trigger ovulation. At this stage you will also likely be visibly bloated, uncomfortable, and ready to have the follicles aspirated in order to get some relief.

Step Four- Grow the Heck Up and Get Out of Here Eggs!

In the last few days of stimulation, you may be monitored daily. This is because timing of the trigger shot it crucial. If you trigger too early, the eggs may not be mature. Too late, the eggs may degenerate. The trigger causes the final stage of maturation, meiosis of the egg.

Meiosis is a process where the egg divides its 46 chromosomes into 23 that will pair up with 23 from the sperm. Failure to divide properly is common and increases with age, which is why fertility declines and chromosomal abnormalities increase as a woman gets older. To put it simply, your eggs get “stickier” as they get older and don’t divide as efficiently, leaving extra or not enough chromosomes at the end of the division process. Most of these eggs will simply fail to fertilize or the embryos will arrest early in the development process. Some can implant and lead to miscarriage, and in rare instances abnormal embryos can grow to be a baby with Trisomy 18 or Downs Syndrome. So this stage is critical.

Without retrieval, ovulation would occur 38 to 42 hours from trigger. Your retrieval will be scheduled right around the 36 hour mark to allow your eggs to be as mature as possible before collection.

It is at this stage that 10 to 20% of cycles are cancelled, usually due to a small number of follicles and/or low estrogen levels. In extraordinarily rare instances a patient may ovulate prior to retrieval which would also cancel the cycle. Even though it is extraordinarily rare, you may be like me and totally freak out about possibly ovulating early for every waking second of those 36 hours. Don’t be like me. It is very unlikely you will ovulate.

Once upon a time there was only one way to trigger ovulation and that was with an intramuscular injection of Human Chorionic Gonadotropin (HCG). Today some clinics trigger with lupron or a combination of HCG and lupron. Typically lupron is used when estradiol levels are very high to decrease the risk of ovarian hyper stimulation syndrome (OHSS). There is some evidence that the HCG trigger is superior, but doctors are learning more and more every day about how to improve the effectiveness of the Lupron or combination HCG/Lupron trigger.

The HCG trigger shot is typically the first of your intramuscular injections (crazy long and thick needle injected into the upper outer quadrant of the buttocks). Ouch!

Image by Gerda via Flickr

Step Five- Your Own Personal Easter Egg Hunt

Now it is time for your RE to go in and get the eggs you have worked so hard to create. Generally, your partner or donor will provide his part of the equation right before or during retrieval so his little swimmers are ready once your eggs are retrieved. He will often be given the choice to collect at home or schedule an appointment to collect at the office.

Image by ntr23 via Flickr

Retrieval is the most invasive and difficult part of the process. You will be sedated during retrieval. Some doctors will put you all the way under, while others use twilight anesthesia. I have experienced both and prefer twilight anesthesia despite the fact there is still a fair amount of discomfort. Even though you are loopy under the anesthesia, its pretty nifty to experience the procedure. Plus at my clinic you hear the egg count as the embryologist reports it back to the doctor as retrieval is happening.

Who doesn’t love immediate gratification?

The RE retrieves the eggs by piercing the vaginal wall with a needle on the end of a special ultrasound probe. The doctor carefully inserts the needle into each follicle and drains the fluid, including the egg. This process takes anywhere from 15 to 30 minutes depending on the number of follicles. Your vitals will be monitored for at least an hour after surgery and you will need someone to drive you home. Because the meds stay in your system, you will need a full day off from work but can plan to return the next day. You will be uncomfortable for a day or two and can take acetaminophen to help with the pain.

Every follicle contains an egg or else it wouldn’t exist, however some women retrieve fewer eggs than the number of follicles seen on an ultrasound. These women are often told some follicles were “empty”. That is not the case. What really happened was the egg was simply not ready to come out of the follicle. The trigger not only starts meiosis, it also loosens the egg from the follicle wall. When this does not occur, it is impossible to remove the egg from the follicle. Even if it could be removed, this egg would not yield a healthy embyro. Timing of the trigger is one possible explanation for this, as well as general egg quality.

After retrieval you will begin taking a few other medications which vary based on patient and clinic, but you will definitely take an antibiotic of some sort and an anti-inflammatory. If you are doing a fresh transfer, you will also start progesterone supplementation on the day of retrieval to prepare your lining to receive your embryos in three to five days.

There are many ways to take progesterone including vaginal suppositories (both gel and tablet) as well as painful intramuscular injections. Many doctors prefer the injections until after pregnancy is established to avoid uterine contractions during the implantation period. Progesterone supplementation will continue until around 10 weeks when the placenta takes over its production.

Step 6- It’s Baby Making Time

Once the eggs are harvested they are swept away to the lab to be united with the sperm that has now been prepared for insemination or intra-cytoplasmic sperm injection (ICSI). With insemination, sperm will be placed in a petri dish and left to their own devices to find and fertilize the egg. With ICSI the embryologist will pick one healthy looking sperm from the sample and inject it directly into the egg.

Image by Wellcome Images via Flickr

This process begins four to six hours after egg retrieval. The would-be embryos are placed in an incubator and assessed 16 hours later to determine if fertilization was successful. Successful fertilization is indicated by the presence of two pronuclei. Fertilized eggs will be placed in culture media that mimics the fluid found in the fallopian tubes, which is where your embryo would be at this stage if fertilized in a natural cycle.

You will know how many eggs you have right after retrieval, but you have to wait a whole day to find out how many of those eggs fertilized. A whole day!

Two days after fertilization the embryos will be briefly assessed to ensure they are dividing properly. If there are a number of embryos dividing properly, the embryologist may decide to allow the embryos to continue to grow to the blastocyst stage on day five or six. If only a few embryos are dividing properly, the embryologist may suggest a transfer on day three after retrieval. You will typically receive a report on day three even if you are transferring on day five.

Our Day Two Embryos From Spork’s Frozen Cycle

There is an ongoing debate about whether it is best to transfer embryos on day three or day five. Many doctors believe that embryos that don’t make it to blastocyst stage on day five or six in the lab would be unlikely to do so if transferred to the natural environment earlier. By allowing weak embryos to die off in the lab you increase the chances of the remaining embryos implanting. The opposing view argues that it is impossible to replicate the womb perfectly and that embryos are better off when they return to the natural environment as soon as viability can be determined.

If your embryo is transferred on Day 5 or 6, it will be placed in new culture media that replicates the uterus, which would be its environment three days past ovulation in a natural cycle. A blastocyst will contain 80 to 100 cells and has a clear inner cell mass (ICM) and trophectoderm visible. The ICM will eventually become the baby and the trophectoderm will become the placenta.

Day 3- Embryo has 6 to 8 cells. Embryo could be either biopsied for testing or transferred on this day.

Day 4- Morula stage. Embryo compacts into a small ball of 16 or so cells.

Day 5- Blastocyst stage. Embryo expands and a clear ICM and trophectoderm are visible.

Day 6- Last day an embryo can survive in an incubator. It must be transferred or frozen at this stage.

Step 7- Mama I’m Coming Home

It’s time! Whether you transfer on day three or day five, the time has finally arrived to welcome your embryo or embryos back home where they belong. The transfer is an important part of the IVF process even though it is usually very simple and totally painless. In fact, the procedure typically only takes only about 5 minutes.

Because of this I found it to be a lot like my wedding day. We worked so hard and put so much effort into something that flashed by in the blink of an eye. Still, just like a wedding, it is a very special time which is sure to leave you and your partner beaming and exhausted.

You may make the final decision on how many embryos to transfer and what to do with the remaining embryos immediately prior to transfer. This way you have the most recent embryo development information available to aid in this difficult choice. Your doctor will give you pros and cons but the final decision is up to you. Any remaining embryos can be frozen (cryopreservation) for future transfer.

While the decision on how many to transfer is up to you, there are limits to what some countries and doctors will allow. No sensible doctor would have let Octomom to do what she did. We in the infertility community genuinely despise her doctor for the bad rap he gave IVF and all the explaining we have to do as a result of his ineptitude.

Image by Alanak via Flickr

Once you have determined how many to transfer, the embryologist will load the embryos into a special catheter designed for transfer. The doctor will slowly inject the embryos into your uterus using guided ultrasound. Unlike embryo retrieval and follicle monitoring, this ultrasound will be an abdominal scan in order to avoid potential uterine contractions and to allow a clear path to the sweet spot. This means you will need to have a full bladder for the procedure to allow the doctor to have a clear view of your uterus.

Image by Carbon Arc via Flickr

The full bladder is the bane of the IVF patient’s existence. It is very difficult to know when and how much to drink in order to get the bladder full enough for a successful transfer but not so full that you wish for death in the hour you lie immobile and holding it after transfer. Follow the advice of you doctor, but I have been told 8 ounces 45 minutes to an hour prior to the procedure is more than enough.

The “sweet spot” from our last transfer

Once your RE locates the “sweet spot” he will release the embryos along with a puff of air. The catheter will be given to the embryologist to look under the microscope and ensure that the embryos cleared and ended up in the uterus. You will remain immobile and reclined for 15 minutes to an hour. Some clinics prescribe bed rest for a day or two after transfer while others do not. Recent studies suggest that bed rest can actually decrease success rates, but the jury is still very much out on this one. I personally like the day of bed rest so I don’t have to return immediately to the real world and can luxuriate in my potentially pregnant state. Plus my husband has to take care of me. That’s why I think clinics will be slow to remove the requirement if it is indeed proven to be unnecessary.

The next step is the blood pregnancy test, also called a “beta” which measures the level of HCG in the blood. HCG is produced by the embryo after it implants into the uterus beginning as early as 7 days after retrieval. Timing of the test varies by clinic, but typically falls 14 days after retrieval.

HCG is the same hormone that is usually injected to trigger ovulation. For this reason, many women will start taking home pregnancy tests after trigger to see when the HCG tests “out” of their system. After the HCG is tested out, any positive pregnancy test is likely to be a real pregnancy and not just remaining HCG from trigger. HCG is generally gone after 10 days but I personally don’t mess with taking home pregnancy tests during fresh cycles. There is too much potential for the HCG trigger to mess with my already overly worried mind.

If you are pregnant, a second pregnancy test will be ordered to ensure that HCG levels are rising normally. You will also continue to be monitored by your clinic through blood work and ultrasounds until week 10 or 12 of your pregnancy before you “graduate” to your regular OB or other specialist.

If you are not pregnant, you will schedule a consult with your doctor to review the cycle and discuss next steps. It’s a good idea to bring a list of questions to this appointment to help stay on task with this discussion. If you aren’t pregnant, its important to note that many people do not get knocked up in their first IVF. In the same way that fertile couples don’t always get pregnant the first month they try to conceive, IVF can take some time.

This is a hard pill to swallow given the expense and emotional strain involved. The general rule of thumb is that the majority of couples will get pregnant by the time they complete 3 full IVF cycles. After the third cycle the success rates plateau and it may be time to consider alternatives like donor eggs, donor sperm, gestational carriers, adoption, and living childless. However this is a generalization and your treatment plan and next steps should be determined by you and your spouse with the help of a trustworthy Reproductive Endocrinologist.

Whatever your outcome, I hope this post will help you understand a little more along the way. If you want to have a child you will have one, although it may play out differently than you dreamed.

Whatever you do, don’t give up on your dream until you are sure its the right time for you.

Best of luck to you. Take care of yourself and your relationships on this journey.

We are finally in the same state as the 100 celled baby we are taking back home on Saturday.

Even though real romance is a no-no at this stage in the process, we are making the most of it by tagging on two days of snowboarding prior to transfer. This is our fourth trip to Colorado for fertility purposes and we are infusing some fun and sport into the journey. On the last trip we ventured to Vail. Now we are giving Breckenridge a go. We both love boarding and are paying for the flights, so why not? Especially since I hope to be done with boarding for the next nine months.

We discovered a rustic mountain lodge only a few miles away from Main Street and were upgraded to a mountain view suite without even having to play the “we are here to get pregnant card.” Sweet.

We arrived just in time for some grocery shopping and a leisurely dinner last night. We hit up the local Safeway to pick up a prescription, beer for Bill, and water for me. Turns out the labs from Sunday yielded low estradiol levels, again. Now I am on four estrogen patches and also talking estrace orally twice a day. Holy estrogen overload!

Once again, this shouldn’t be an issue as long as we fix it by Thursday morning. The lining is nice and thick and my progesterone levels are right where they should be to make a cozy home for baby.

When the clinic called to relay the need to pick up more meds, we also learned that Bill has to have blood work done prior to transfer. They want to make sure he hasn’t picked up any communicable diseases before they send us home with a baby. The sadistic side of me is eagerly anticipating him getting poked too. Its only fair.

But today we put all the meds, labs, and procedures in the back of our minds as we enjoy two pristine days on the slopes.

Breckenridge is crawling with people, its one of the busiest weeks of the year. The first board rental store we stopped at was completely sold out of boards and bindings for Bill. We start the search anew today. Worst case scenario, we will buy new ones. Both of our boards back home are more than 10 years old and its past time. Still, the trip to Breck is stretching our already taught budget and we hope to score rentals.

Despite the crowds and not having a reservation, we consumed a delicious dinner without having to wait. Tonight we aren’t risking it and made reservations at an upscale, gluten-free, vegetarian restaurant. Simply perfect for our pre-baby making meal.

I booked an apres ski couples massage in the hotel spa today. Between shredding the hills today, the massage tonight, and the clean dinner I am doing the best I can for my body and should be toxin free by Thursday.

As far as how I am doing, physically I feel amazing. Stopping lupron has done wonders for me. Emotionally, I continue to feel unusually optimistic about this cycle.

On the plane yesterday I meditated multiple times. I visioned all the cells in my body breaking apart and joining with all the matter in the universe, including all the cells of our chilly little embryo. Then I imagined bringing those cells back into me. It was beautiful. I feel as though my body is calling our baby home. I have felt this way before, but this time is more profound.

Only two more days and we will be reunited with our baby and will hopefully be done with trips to Colorado for “medical purposes.” While we appreciate writing off the travel expense on our taxes, the next time we come back we hope it is as a family of four.

There still may not be much room for romance then, but that will be okay with us.

My middle sister asked me this question tonight, catching me off guard. She reads the blog religiously so I assumed that she of all people would know exactly how I am doing. The question made me realize that blogging daily and pouring your heart out on the world wide web doesn’t really tell people how you are actually holding up in the IVF process.

I am okay. Just okay, but that’s pretty good.

At times I am tempted to treat this blog like a twitter post and just quickly check in with 140 characters worth of emotion, experiences or wit. If you read regularly, you know I don’t do that. I want my words to have meaning and beauty which takes thoughtfulness, work, and time. But if I posted quick tidbits and insights they might tell more to the reader about my state of mind than a 1000 words of carefully constructed prose.

Let’s give it a try:

Ultra comfort? I can’t believe the manufacturer plastered that on my lupron syringes. Ultra comfort my @#&! You should see my bruises. #criminallyfalseadvertising

Nervous/anxious/excited about my ultrasound and blood work tomorrow. The trip is paid for. I’ll freak if we don’t get a green light and have to cancel. #whatsafewthousandmore

Overcommitted myself this week. Totally swamped as we get ready for our trip. I did this last time too. Ugh! #busyismycopingmechanism

The higher dose of estrogen this cycle made me cry at work again today. Embarrassing! And…Um…I have other estrogen symptoms too. #havetowearmymaternitybra

Sleep! I need sleep! Sooooo tired… Anxious and over-thinking. Laid awake until after 1AM and Spork got up early. #needcoffeeandnotallowed

OMG…What will we do if we get all the way to Denver and the embryo doesn’t survive the thaw? #2daysofdrunkendebaucheryatvail

No estrogen fueled fights yet. We are getting good at this! I think writing about all this is helping. #mybloggingsavedmyhusband

So that’s how I am and its common for me at this stage. The week before transfer is always hardest, stress escalates at this juncture and I vacillate between titilation and terror. Titillation at the possibility of being pregnant in a week and terror that I may not be or that something could go wrong.

If IVF is a roller-coaster, and it is, this is the top of the biggest hill right before that heart stopping drop.

Click…click…click… click… (deafeningly silent pause)…

So, all in all I am ok. Thanks for asking sis. It helps to stop and think about it.

I had my first labs done this week. The time has come to regularly roll up the sleeves and put those lucky veins to work. Except for visiting with the lovely ladies that work in registration who have been our cheerleaders for the last four years, I hate going to the lab. Hate may be a strong word. I do like discovering how we are progressing and blood work is a necessary part of it, but I hate blood draws. Even after four long years.

Giving myself shots in the comfort of my own home is one thing, but having my blood sucked out of me at the crack of dawn is another. No matter how gentle the tech is, it hurts. Cosmetically it is also super sexy. By the time we transfer I will look like a heroin addict. Thankfully its still -20 degrees Fahrenheit in the mornings so nobody sees my track marks except Bill.

Unfortunately the results of my blood work this week weren’t what we hoped. My estrogen level was low for this stage of my cycle which means yesterday I jumped from one estrogen patch to four.

The good news is this won’t create any problems with the transfer and its nothing to worry about at all. We are simply adjusting and bringing the levels in line with where they should be to create a thick endometrial lining by the time we bring our embryo home. Making adjustments like this are the reason we monitor levels so closely as we prepare for the big day. I am excited that we are doing something a little different this time as well, since following the status quo last time didn’t work out for us.

The bad news is this adjustment does skip a whole week of ramp up period where I would normally have increased to two patches tomorrow, three next week, and then four a few days before transfer. It also means I will be on high levels of estrogen for an extended period of time. In fact, it will be the highest level of estrogen I have taken for the longest period since I started trying to conceive.

So things could get pretty interesting around here. With our last cycle I found myself in tears in a coworker’s office just two days after increasing to four patches. There was no reason for crying. I just weep when I’m on it, most of the time for no reason and unexpectedly.

Good times.

Moodiness is just one of the many side effects of estrogens (also called oestrogens, hence the title). I use the plural here because there are actually four types of estrogens which support a variety of important functions in both males and females.

E1- Estrone. Dominant in menopause

E2- Estradiol. Large and in charge during the reproductive years

E3- Estriol. Rules the roost during pregnancy and produced by the placenta

E4- Estertrol. Present in pregnancy and produced by the fetal liver until birth

The type of estrogen prescribed in a medicated IVF cycle is E2. It can be confusing at first because E2, estradiol, and estrogen are often used interchangeably by doctors, nurses, pharmacists and lab techs. Its all the same stuff and performs essential functions in baby making, natural or otherwise.

In a natural cycle Estradiol is produced by the ovaries and stimulates the release of LH which causes ovulation. E2 also causes the uterine lining to thicken in order to prepare for implantation. That’s why I am taking it now, to develop a welcoming place for our embryo to settle into for the next nine to ten months.

This is necessary during IVF because our doctor has suppressed ovulation and taken control which means my body will not produce the levels of estrogen necessary to support pregnancy naturally.

In a natural pregnancy with ovulation, the follicle in the ovary that releases an egg will turn into the corpus luteum which provides estrogen support until the placenta fully takes over sometime before 10 weeks. As a result, I will be on four patches of estrogen from now until I graduate to our regular OB at 10 to 12 weeks if we are pregnant. I have taken estrogen in two different forms, a pill and a patch (pictured above).

Hormones are just down right strange and confusing little boogers and estrogens are no exception. Estradiol is unusual because it has as many health benefits as it has nasty side effects. It has been shown to improve libido, cardiovascular health, metabolism, bone formation, and lung function. On the flip side, it can exacerbate breast cancer, cause endometrial cancer, and has been shown to lead to blood clotting.

It is so-not-funny that most of these common side effects are also pregnancy symptoms. This can really mess with your mind after transfer when progesterone joins in to help estrogen in an effort to drive you completely batty, wondering if what you are experiencing are side effects or pregnancy symptoms.

I am already starting to look pregnant due to the water I am retaining and the growth and thickening caused by the drug. I even catch myself rubbing my soon to be pregnant belly from time to time. Just getting in a little bit of practice in preparation for the real thing.

The self-discovery I experience as a result of IVF never ceases. When I began this blog, I had every intention of posting something humorous about infertility every day. I vowed to readers I wouldn’t complain. I promised to not provide gory details of ultrasounds and other tests. And above all I promised no pity parties or rants. My goal was to bring a little levity to an otherwise heavy topic while also reminding myself to stay positive and laugh.

What was I thinking?

Positivity and humor are still great goals and I am not planning to dive head first off the deep end, but I am only on day two of estrogen and I am already throwing in the towel on trying to be funny every day. I don’t know how I forgot about the effects of that nasty lupron and estrogen cocktail. It’s like having a never-ending hang over. The headaches are constant and pounding. Fatigue has wracked my body. The moodiness is already wickedly bad.

The scary thing is that it is only just beginning. I am wearing only one estrogen patch at this stage in my cycle. By the time I fly out west to reunite with my long lost embryo I will be wearing four patches. Tears will be flowing and fights will be picked. I know myself and my body and its inevitable. Comedy writing on a daily basis is not in the cards.

You can already see the effects of the drugs in my writing. My posts have grown longer and just a wee bit darker as the injections have worn on and the patch was added. What I am learning is that there are just times when I am not a funny person. There are times when I barely feel like a person at all.

Freaking out and worrying are also tell tale signs of successful progression in an IVF cycle that are sure to make humor elusive. Yesterday I was convinced I hadn’t shed my old lining and that I shouldn’t start my patches until I did. I pleaded for an ultrasound to confirm that it was gone and I was getting a fresh start on developing fertile ground for implantation. As expected the ultrasound was fine. Despite the good news, I still dialed up my clinic twice today for no good reason to ask a couple of questions that don’t really need answers until March, if ever.

The questions were about the odds of success of our lone embryo. The doctor already told us the embryo had about a 35% chance of making it to a real life baby. But yesterday I spent some time with Dr. Google, never a good idea, and began wondering what factors went into the creation of that number. Did the doctor take into consideration that the embryo had to be thawed and retested because the first genetic test was inconclusive? What are the impacts of an extra thaw and biopsy on our delicate embryo? What are the odds that we will get all the way to our clinic and the embryo won’t survive the warming process?

I pestered my clinic with these questions even though I laid in bed late into the night last night reminding myself that the answers are irrelevant. The clinic has a 95% survival rate for thawed embryos. And even if the odds were lower, its not as if we aren’t going to go through with the transfer. What would this information change? Nothing good can come from this knowledge. I have already been meditating on the only statistics that matter, my very own 100% success rate. I visualize a SART data report with my name on it and in every column my results are 100%. Why would I want to mess with that image and its mojo by finding out what some doctor thinks?

One word, hormones. Hormones make the sane insane. They make the intelligent foolish. They make the happy sad. And above all else they make the confident worried. I don’t like worried.

Worry is a meditation on shit.

Worry and hormones aside, there is another reason that I am having troubling channeling my inner comedian.

The real self-discovery has been that its not only that I am not always capable of humor, I have also discovered that I want to try a variety of types of writing. I don’t just want to tell cute stories about IVF, I want to pour my heart and soul out on a page and see what it looks like in black and white. I want to hear my emotions and deepest thoughts roll of the tongue of the voice in my mind. I want the therapeutic jolt of liberation I feel when I hit publish on something I have created. The writing process won’t allow me to limit my life to one genre.

With all this in mind, I made a little change to the Laughter Through Tears subtitle today. Yesterday it read “for those in search of the lighter side of infertility.” Today its simply “In search of the lighter side of infertility.” It’s a subtle change, but its recognition that I can’t promise anyone levity every day, especially not myself. I can’t always be funny and witty. However I will commit to always being in search of the lighter side. For you and for me.